Is there any evidence of benefit for pre-hospital intubation of patients with traumatic brain injury?

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I recently found myself in a debate with an emergency physician regarding the benefit of intubation by first responders of patients suffering a traumatic brain injury.

I felt very strongly that this would be beneficial in helping to avoid secondary brain injury due to hypoxia, as well as negating the risk of aspiration. She however very strongly disagreed and claimed there were even studies showing the lack of benefit of pre-hospital intubation.

2 Answers

E. von Elm, a Cochrane researcher, recently published a review asking this very question.1 In short, your ED friend is probably right:

“…the available evidence did not support any benefit from pre-hospital intubation and
mechanical ventilation.”

It’s worth noting that neither did the evidence show a consistent harmful effect from pre-hospital intubation. The available studies (17 studies, 15,335 patients, 1985 to 2004) were also of relatively low quality, with only three of class 2 LOE, and the remainder class 3.

“However, tracheal intubation can also be harmful. If performed in unfavourable settings and by unskilled staff, failure and resulting oxygen desaturation are
more likely. Intubation on scene may increase the risk of early onset pneumonia. Hyperventilation during the pre-hospital period can aggravate cerebral ischaemia and secondary brain injury with
increased mortality. Mechanical ventilation with uncontrolled positive pressure may reduce venous return from the cerebral circulation and increase cerebral oedema. Hence, it is controversial whether patients with severe TBI always benefit from pre-hospital intubation and mechanical ventilation.”1

Although, “…there were few reports of harm from intubation in the included studies.”

The take home message is that like many things, pre-hospital intubation is not a cost-free intervention, and has no proven benefit. Outcomes after TBI are likely more dependent on other systemic factors than on whether or not you are intubated.

Good question. On the face of it I find it hard to believe that pre-hospital intubation could do anything but help. Protect the airway. Correct any airway obstruction. Deliver high concentration oxygen. Control CO2. All good right?

But then you need to consider:

Whether or not the first responders are able to reliably and quickly intubate the patient.

The fact that any intubation, even if fast, will delay arrival at a hospital.

Whether intubation really is beneficial and improves outcomes. The ALS/resuscitation literature shows no definite benefit for intubation as part of Advanced Life Support – use of laryngeal masks is part of the algorithm when intubation skills aren’t available.

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